Failure to Implement Ordered Pressure-Relieving Boot for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered interventions to promote safety and healing of a diabetic foot ulcer for one resident. The resident had multiple diagnoses including COPD, acute respiratory failure, type 2 diabetes mellitus, a non‑pressure chronic ulcer of the right plantar foot with fat layer exposed, lymphedema, CHF, and hypothyroidism, and required extensive assistance with ADLs and mobility. The MDS documented a diabetic foot ulcer, and the care plan identified a right plantar foot wound related to diabetes with goals for weekly improvement and interventions including twice‑daily wound treatments, non‑weight‑bearing (NWB) status to the right lower extremity, staff assistance with ADLs, and skin inspections. The facility’s wound log documented a sizable right plantar diabetic ulcer. Wound physician notes on multiple dates documented an order for a pressure‑relieving boot for the resident’s feet, and the regional clinical director acknowledged that these electronically signed notes should have been processed as physician orders. However, review of the care plan, physician orders, and treatment administration records showed no documented order for a pressure‑relieving boot. The wound physician stated he placed the order for a pressure‑relieving boot in his notes as part of his usual practice for foot wounds and that the resident needed to keep pressure off the right foot. The assistant DON/wound nurse, who stated she makes rounds with the wound physician and enters orders based on those rounds, reported she had never seen the resident with a boot and was not aware of the pressure‑relieving boot order in the wound physician’s notes. Staff and family interviews further demonstrated that the ordered pressure‑relieving device was not implemented. A CNA reported the resident was often noncompliant with lying down and elevating his feet, that his foot was always wrapped, and that she had only seen heel protectors a couple of times when he was in bed, but never any kind of boot while he was up in his wheelchair. A family member stated the resident had a long‑standing diabetic foot wound, was NWB on the right foot, and that she brought a specialized boot from home at admission but never saw the resident wearing that or any boot during frequent visits. A PTA recalled the family‑provided pressure‑relieving boot did not fit and was unsure if anyone attempted to obtain a better‑fitting boot. An RN stated she had never seen the resident with a boot and was unaware of any boot order. The facility’s preventative skin care policy allowed for pressure‑relieving devices and required proper fitting of devices, but no pressure‑relieving boot was obtained or consistently used for this resident despite the wound physician’s documented order.
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